Tuesday, June 06, 2017: Initiatives Highlight Potential of Community Pharmacy

This interview is published in the latest edition of Scottish Pharmacist (page 18) at http://bit.ly/2rRizwa

As NHS Forth Valley celebrates the first anniversary of its Pharmacy First programme and Inverclyde pilots an extension of the Minor Ailment Service (MAS) to all patients, John Macgill asks the Operations Director of Community Pharmacy Scotland, Matt Barclay, for his assessment of these initiatives.

MB: This is all building on the policy agenda to move services from secondary to primary care and, within that, supporting our GP colleagues. Hardly a day goes by when there isn't something in the news about how they are stretched and under pressure. It's about us as pharmacists doing our bit to try to engage with fellow professionals, and also engage with the public to promote pharmacy as a first port of call six, often seven, days a week, for an extended range of services, making best use of the pharmacy teams and the pharmacy professionals in community pharmacies to get people seen at the right time in an appropriate manner and dealt with efficiently and effectively in a community pharmacy setting.

In our manifesto for the Scottish Parliament elections in 2016 we made it clear that there is a place within our pharmacy contract for an evolution of services to support new ways of working, and that's where community pharmacy can certainly do our bit.

JM: The extended Minor Ailment Service pilot by Inverclyde Health and Social Care Partnership launched earlier this year. But unlike the MAS elsewhere, it's open to every local patient to register?

MB: That is correct and it will be interesting to see how that impacts on access and numbers of patients registered in the service because it does open it to everyone who is registered with an Inverclyde GP. Again, the thought is that this is taking these patients potentially out of the queue of people to see a GP. They do say that perhaps 30 to 40 per cent of GP consultations can be for minor ailments, up to 5 per cent of A&E presentations as well. So, if we are having some sort of dent on that then there is a health economic argument that that is more cost-effective. And it's better for patients. The additional cost in terms of any prescribing is going to be small in comparison with the cost of, say, an A&E visit.

The success of this will be down to whether we can change the public's mindset to make them aware that pharmacy can do this for them, and then see how they can access these services responsibly. At the moment, community pharmacies are restricted in how they can advertise these services and this is something that we have talked to the Scottish government about on numerous occasions. We can only use Scottish Government approved literature to promote the services and that tends to be just a poster in the window of the pharmacy and perhaps a few leaflets. Certainly, in Inverclyde there has been a concerted effort between the health board and Inverclyde GPs and community pharmacy teams to have posters in both the GP surgeries and the pharmacies and for everyone to know all about it. And it goes beyond making more patients aware of it to there also being a definite referral pathway in the GP practices and community pharmacies where there is an expectation that if a patient comes with a minor ailment or one of the extended conditions that the pilot has been looking at, then they will be referred into the local pharmacy.

JM: Outwith Inverclyde, is there a downside to the MAS at the moment of people thinking they are eligible when they are not?

MB: That is a challenge for community pharmacy teams. I have been in that position myself. I have had a patient who has come in who is not eligible for the MAS and I have to explain to them that this is not something that they can use. Just trying to find out the exemption status of a patient can be awkward. Of course, this wouldn't have mattered if the same person had come in with a prescription from their GP as the eligibility is no longer a consideration in Scotland.

JM: What impact do you think it would have if the Minor Ailment Service was open to everyone?

MB: It would take away that bureaucracy and that barrier for patients and for community pharmacy staff. There is to be a detailed evaluation of the Inverclyde pilot, which should show the positive impact for the public accessing the service, and we will be able to see the impact of the awareness-raising on the registration numbers and the impact on prescribing under the Scheme.

Under the current MAS, out of a population of 5 million people in Scotland, just under 50% of people are eligible for it. We have just short of 900,000 currently registered so it's reasonable to suggest that we could see numbers double. The evaluation will be very interesting, also, in its qualitative evaluation of the patients' experience: would they have gone to their GP or A&E? Would this make them think twice about where they should go in future?

JM: But it is by no means a long list of medicines under the MAS and also Pharmacy First. You are quite restricted as a pharmacist as to what you can prescribe compared with a GP.

MB: Like GPs there is a local formulary in place for the conditions that are defined as a minor ailment or included under Pharmacy First. Of course, while we by and large follow this, ultimately a pharmacist can make a professional clinical decision to move outside that formulary to treat a condition that comes under the MAS with a medicine that isn't on the formulary.

JM: We are moving to a national formulary so should there be a national minor ailments formulary?

That is something that I think pharmacists on the ground would quite like, particularly pharmacists working across more than one health board. With minor ailment formularies, there is a degree of similarity between them but enough differences for some of my colleagues to find that a product they are recommend to use for a condition in one board area is not included, and replaced by something else, on a neighbouring formulary.

JM: Is the fact that you don't yet universally have access to the emergency care summary hindering progress for community pharmacy?

I think certainly that we are getting to that point now. We, alongside our colleagues at the RPS, the Royal College of Nursing and the allied health professions, recently developed a statement on appropriate access to medical records for pharmacists and other healthcare professionals. We think appropriate access would be hugely beneficial for patients and I think would be a huge enabler for us to deliver services in a more seamless way.

Working as I do out of hours, it would mean I could have appropriate access without having to phone NHS 24 and asking the patient in front of me for permission. I don't want access to everything but it would make the process much better if I was able to see their diagnosis, medication history, allergies and perhaps recent blood results. I like the phrase 'role-based access'. For me that means that the information that would be useful for me is all that I need.

Working as a locum in a pharmacy across the road from a GP surgery on a Saturday morning, patients are astonished when they realise that I cannot see what the GP prescribed for them the day before. And they are sometimes not too pleased that I need to go through a convoluted 10-minute process through NHS24 to get that information. And, by the way, you will need to speak to NHS24 to give your consent. They say, "but I want this now!".

JM: What is the potential of community pharmacy that perhaps the extended MAS pilot and Pharmacy First are demonstrating?

The movement of resource from secondary to primary care for a lot of reasons is probably not quite happening for me. There isn't necessarily endless capacity. We are not sitting around all day in community pharmacy, we are very busy.

I think the potential really is there through the access we offer, through the skills that we have. I think the development of the new roles within primary care is recognition of the profession. Indeed, I know some health boards are adopting a mixed model of using community pharmacists to do some of the primary care pharmacist roles a couple of days a week. Some of the early indications are that that approach is working for patients. The challenges of workload are considerable but, hopefully, some of the automation initiatives and innovations around how we use our people, will address this.

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